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BACKWATER PREVENTION DEVICE FINAL <br /> a•� INSTALLATION CHECKLIST <br /> inslallalion Company Name and Conlact Info:�7R'3'g" 9-f �l�u/ �L� �r-l-l�9-v�z � <br /> Date Backwater Prevention device(8WD)was installed: � '�5 ate this fortn was completed: � � <br /> Installation Property Owner Name and Contact Info ��►'1'l.Al. 1'�.1���'�.� <br /> Praperty Address: ��0/X `L�i4�� �� <br /> Pre•Installalion Inspection Checkiist: <br /> All items must be checked 'Yes'in order for a�WD to be consrdered/or installation <br /> Is there a basement or level of the house Ihat is at or near assumed sea�er main elevalion? es ❑No <br /> Are ihere fixtures in ihe house located below the upslream sewer manhole rim etevation?[r�'fes ❑ No <br /> Is ihe side sewer currently UNPROTECTED(rom sewer backups(does not have a BWD installed�? es ❑No <br /> Site Inspection Checklist: ( o <br /> All items musl be checked'Yes'6elore inspection is considered complete )'� `0 C�°wj , <br /> Was side sewer TV inspected from building ro sewer main� [�}Yt�s� No Condition: ° �� w�`{ • <br /> Does side sewer have at leasl 1'/o slope lrom the building lo sewer main7 [�]Xes ❑ No Describe: <br /> Have all buiiding sewer drain connections lo the side sewer been identified and localed? �es ❑No <br /> Have all property storm drainage connections to Ihe side sewer 6een identified and located7 [�-Yes ❑ No <br /> Has properiy been evaluated lor drainage defciencies with findings communicated to property o»ner? (�es ❑ No <br /> Installation Details: <br /> What type and brand of 8WD was installed at this sil Clean Check BW ,Grinder pump,etc.� ������ <br /> Where was Ihe device installed (general description, attach map)? � <br /> Was there any other sewer or storm drainage w r completed m conjunclion with the BWD work?Is so please descnbe: � <br /> Q1�.Q-_ <br /> Inslaliation Checklist: <br /> Are all downspouts and sile drainage disconnecled from upstream oi Ihe BWD? � es ❑No Comments: <br /> Does BWD positioning meels minimum slope requiremenl 0(>1%7 ��'c�[] No Comments: <br /> Can BWD be pulled out for inspection and maintenance afler loosening ihumb screw? [�1`e�'� No <br /> Is BWD locked inlo the proper position and Ihu b screw tightened? �-Yesr�No <br /> Circle ihe BWO covec irrigation co lan scape area)I t ffic load beanng cover(drive surtace)1 access hatch(building) <br /> Was propeity owner shown the localion of the installed BWD? es ❑No Comments: <br /> Property Owner's Signalure: G GFu�-� � Date. b'�l8'/5 <br /> Installer's Signalure Date: ����� <br /> Revision:2 1 Friday,September 17, 2014 <br />